Preventive and Comprehensive Dental
Mass Advantage contracts with the Dominion PPO network. Your 2026 dental benefit coverage is based on using in-network Dominion PPO providers. If you choose to receive treatment from a licensed dentist outside of the Dominion PPO network, the procedures covered under our plan will be reimbursed up to the 2026 maximum benefit limit for your dental coverage (see your Evidence of Coverage for more information). You are responsible for any amounts that exceed your maximum benefit limit for both in-network and out-of-network dental services.
| Benefit | Basic (HMO) | Plus (HMO) | Premiere (PPO) | Extra (PPO) |
|---|---|---|---|---|
|
|
In-Network: Medicare-covered Dental: $30 copay Out-of-Network: Medicare-covered Dental: $45 copay In-Network and Out-of-Network: Non-Medicare covered Dental:
|
In-Network: Medicare-covered Dental: $45 copay Out-of-Network: Medicare-covered Dental: $65 copay In-Network and Out-of-Network: Non-Medicare covered Dental:
|
|
$1,000 annual allowance for comprehensive services |
$1,500 annual allowance for comprehensive services |
$1,000 annual allowance for comprehensive services |
$1,500 annual allowance for comprehensive services |
| Basic (HMO) |
|---|
|
|
$1,000 annual allowance for comprehensive services |
| Plus (HMO) |
|---|
|
|
$1,500 annual allowance for comprehensive services |
| Premiere (PPO) |
|---|
|
In-Network: Medicare-covered Dental: $30 copay Out-of-Network: Medicare-covered Dental: $45 copay In-Network and Out-of-Network: Non-Medicare covered Dental:
|
|
$1,000 annual allowance for comprehensive services |
| Extra (PPO) |
|---|
|
In-Network: Medicare-covered Dental: $45 copay Out-of-Network: Medicare-covered Dental: $65 copay In-Network and Out-of-Network: Non-Medicare covered Dental:
|
|
$1,500 annual allowance for comprehensive services |
Diagnostic and Preventive Dental services include:
- Prophylaxis (cleanings) – limited to 2 per calendar year
- Evaluations
- X-rays
- Fluoride Treatment
- Comprehensive Dental services include:
- Restorative Services (fillings, inlays, onlays, and crowns)
- Endodontic Services
- Periodontic Services
- Prosthodontics, removable dentures and fixed bridges
- Oral and Maxillofacial Surgery (extractions)
- Adjunctive General Services (palliative treatment, deep sedation/general anesthesia)
- Teledentistry (synchronous and asynchronous, must be accompanied by a covered procedure)
This is a brief summary of covered services only. Please refer to the Evidence of Coverage document for a full listing of covered services. Dental services are administered by Dominion Dental Services, Inc. You can access the Dental Provider directory here or by contacting Member Services.
Frequently Asked Questions
Preventive dental includes services like routine exams, cleanings and x-rays. For a full list of covered preventive dental services, please see your Evidence of Coverage (EOC)
Comprehensive dental includes services like periodontics, extractions, restorative services and more. For a full list of covered comprehensive dental services, please see your Evidence of Coverage (EOC).
Yes. We have contracted with the Dominion PPO network which means all HMO and PPO plan members, have the ability to see dentists both in and out of the Dominion PPO network for preventive and comprehensive care.
Preventive and comprehensive benefits are calculated using a Maximum Allowable Charge (MAC). Members are responsible for any difference in amount charged by an out-of-network dentist and the MAC per> procedure. Billing arrangements are made between the member and the out-of-network dentist.
If you receive treatment from an out-of-network dentist, you may be required to make payment in full at the time of service. You will then need to submit a Direct Member Reimbursement Form to receive payment.
Our Member Navigator team is here to help with any benefit coverage or network questions or concerns. Member Navigators are available: (844) 483-1444, TTY:711 Monday through Friday from 8 am – 5 pm.
Contact
For more information contact us at (844) 918-0114 HMO or (844) 915-0234 PPO / TTY:711
We’re available October 1 – March 31, 8:00 am – 8:00 pm, 7 days a week;
and, April 1 – September 30, 8:00 am – 8:00 pm, Monday – Friday.